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  • 1.
    Backman, Olof
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery. Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Freedman, Jacob
    Marsk, Richard
    Nilsson, Henrik
    Laparoscopic Roux-en-Y Gastric Bypass Without Division of the Mesentery Reduces the Risk of Postoperative Complications2019In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 33, no 9, p. 2858-2863Article in journal (Refereed)
    Abstract [en]

    Background: Anastomotic complications after laparoscopic Roux-en-Y gastric bypass (LRYGB) including leaks, ulceration, and stenosis remain a significant cause of post-operative morbidity and mortality. Our objective was to compare two different surgical techniques regarding short-term anastomotic complications.

    Methods: A retrospective analysis of all patients operated with a primary LRYGB from 2006 to June 2015 in one institution, where prospectively collected data from an internal quality registry and medical journals were analyzed.

    Results: In total, 2420 patients were included in the analysis. 1016 were operated with a technique where the mesentery was divided during the creation of the Roux-limb (DM-LRYGB) and 1404 were operated with a method where the mesentery was left intact (IM-LRYGB). Leakage in the first 30 days [2.6% vs. 1.1% (p < 0.05)], and ulceration or stenosis occurring during the first 6 months after surgery [5.6% vs. 0.1% (p < 0.05)] was significantly higher in the DM-LRYGB group. Adjusted odds ratio for anastomotic leak was 0.46 (95% CI 0.24-0.87) and for stenosis/ulceration 0.01 (95% CI 0.002-0.09).

    Conclusion: IM-LRYGB seems to reduce the risk of complications at the anastomosis. A plausible explanation for this is that the blood supply to the anastomosis is compromised when the mesentery is divided.

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  • 2.
    Bringman, S.
    et al.
    Department of Surgery, Karolinska Institute, Huddinge University Hospital, S-141 86 Stockholm, Sweden.
    Ek, A.
    Ek, Å., Department of Surgery, Karlskoga Hospital, Karlskoga, Sweden.
    Haglind, E.
    Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Heikkinen, T.
    Department of Surgery, Karolinska Institute, Huddinge University Hospital, S-141 86 Stockholm, Sweden.
    Kald, Anders
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Surgery . Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Surgery in Östergötland.
    Kylberg, F.
    Department of Surgery, Karlskoga Hospital, Karlskoga, Sweden.
    Ramel, S.
    Department of Surgery, Karolinska Institute, Huddinge University Hospital, S-141 86 Stockholm, Sweden.
    Wallon, Conny
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Surgery . Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Surgery in Östergötland.
    Anderberg, B.
    Department of Surgery, Karolinska Institute, Huddinge University Hospital, S-141 86 Stockholm, Sweden.
    Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study2001In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 15, no 3, p. 266-270Article in journal (Refereed)
    Abstract [en]

    Background: Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation. Methods: A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon. Results: In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8). Conclusion: The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

  • 3. Cengiz, Yucel
    et al.
    Dalenbäck, Jan
    Edlund, Gunnar
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Jänes, Arthur
    Möller, Mats
    Thorell, Anders
    Improved outcome after laparoscopic cholecystectomy with ultrasonic dissection: a randomized multicenter trial2010In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 24, no 3, p. 624-630Article in journal (Refereed)
    Abstract [en]

    In conventional laparoscopic cholecystectomy, dissection with electrocautery starts at the triangle of Calot. In a randomized single-center trial, the fundus-first method (dome down) using ultrasonic dissection was faster, involved less pain or nausea, and had a shorter postoperative sick leave. This may relate to the fundus-first method or to the ultrasonic dissection. In a multicenter trial, 243 elective patients were randomized to conventional laparoscopic cholecystectomy using electrocautery (n = 85) or the fundus-first method using either electrocautery (n = 81) or ultrasonic dissection (n = 77). The fundus-first method had a shorter operating time with ultrasonic dissection (58 min) than with electrocautery (74 min; p = 0.002). The fundus-first method using ultrasonic dissection compared with electrocautery or the conventional method produced less blood loss (12 vs. 53 or 36 ml; p < 0.001) and fewer gallbladder perforations (26% vs. 46% or 49%; p = 0.005). Also, the pain and nausea scores at 4 and 6 h were lower, and the sick leave was shorter (6.1 vs. 9.4 and 9 days, respectively; p < 0.001). The fundus-first method using ultrasonic dissection is associated with less blood loss, fewer gallbladder perforations, less pain and nausea, and shorter sick leave than the conventional and fundus-first method using electrocautery. The difference seems related to the use of ultrasonic dissection.

  • 4.
    Dahlstrand, Ursula
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Sandblom, Gabriel
    Ljungdahl, Mikael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wollert, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gunnarsson, Ulf
    TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 10, p. 3632-3638Article in journal (Refereed)
    Abstract [en]

    Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain. Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)]. A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13-0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09-0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups. Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients' ability to perform strenuous activities such as sports more than TEP patients.

  • 5.
    Dahlstrand, Ursula
    et al.
    CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Surgical Sciences, Uppsala University, Uppsala, Sweden and Department of Surgical Gastroenterology K53, Karolinska University Hospital, Stockholm, Sweden.
    Sandblom, Gabriel
    CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Ljungdahl, Mikael
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Wollert, Staffan
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Gunnarsson, Ulf
    CLINTEC, Karolinska Institutet, Stockholm, Sweden .
    TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 10, p. 3632-3638Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain.

    METHODS: Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)].

    RESULTS: A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13-0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09-0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups.

    CONCLUSIONS: Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients' ability to perform strenuous activities such as sports more than TEP patients.

  • 6.
    Deijen, Charlotte L.
    et al.
    Vrije Univ Amsterdam.
    Vasmel, Jeanine E.
    Vrije Univ Amsterdam.
    de Lange-de Klerk, Elly S. M.
    Vrije Univ Amsterdam.
    Cuesta, Miguel A.
    Vrije Univ Amsterdam.
    Coene, Peter-Paul L. O.
    Maasstad Hosp, Rotterdam, Netherlands..
    Lange, Johan F.
    Erasmus MC, Rotterdam, Netherlands..
    Meijerink, W. J. H. Jeroen
    Vrije Univ Amsterdam.
    Jakimowicz, Jack J.
    Delft Univ Technol.
    Jeekel, Johannes
    Erasmus MC, Dept Surg, Rotterdam.
    Kazemier, Geert
    Vrije Univ Amsterdam.
    Janssen, Ignace M. C.
    Rijnstate Hosp, Dept Surg, Arnhem.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Haglind, Eva
    Sahlgrens Univ Hosp.
    Bonjer, H. Jaap
    Vrije Univ Amsterdam.
    Ten-year outcomes of a randomised trial of laparoscopic versus open surgery for colon cancer2017In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 31, no 6, p. 2607-2615Article in journal (Refereed)
    Abstract [en]

    Laparoscopic surgery for colon cancer is associated with improved recovery and similar cancer outcomes at 3 and 5 years in comparison with open surgery. However, long-term survival rates have rarely been reported. Here, we present survival and recurrence rates of the Dutch patients included in the COlon cancer Laparoscopic or Open Resection (COLOR) trial at 10-year follow-up. Between March 1997 and March 2003, patients with non-metastatic colon cancer were recruited by 29 hospitals in eight countries and randomised to either laparoscopic or open surgery. Main inclusion criterion for the COLOR trial was solitary adenocarcinoma of the left or right colon. The primary outcome was disease-free survival at 3 years, and secondary outcomes included overall survival and recurrence. The 10-year follow-up data of all Dutch patients were collected. Analysis was by intention-to-treat. The trial was registered at ClinicalTrials.gov (NCT00387842). In total, 1248 patients were randomised, of which 329 were Dutch. Fifty-eight Dutch patients were excluded and 15 were lost to follow-up, leaving 256 patients for 10-year analysis. Median follow-up was 112 months. Disease-free survival rates were 45.2 % in the laparoscopic group and 43.2 % in the open group (difference 2.0 %; 95 % confidence interval (CI) -10.3 to 14.3; p = 0.96). Overall survival rates were 48.4 and 46.7 %, respectively (difference 1.7 %; 95 % CI -10.6 to 14.0; p = 0.83). Stage-specific analysis revealed similar survival rates for both groups. Sixty-two patients were diagnosed with recurrent disease, accounting for 29.4 % in the laparoscopic group and 28.2 % in the open group (difference 1.2 %; 95 % CI -11.1 to 13.5; p = 0.73). Seven patients had port- or wound-site recurrences (laparoscopic n = 3 vs. open n = 4). Laparoscopic surgery for non-metastatic colon cancer is associated with similar rates of disease-free survival, overall survival and recurrences as open surgery at 10-year follow-up.

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  • 7.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Ottosson, Johan
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 5, p. 2011-2015Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively.

    METHODS: Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size.

    RESULTS: Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9-20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m(2) at 6 weeks and 28.9 kg/m(2) at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year.

    CONCLUSION: A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.

  • 8. Eiriksson, Kristinn
    et al.
    Fors, Diddi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Arvidsson, Dag
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques2009In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 23, no 5, p. 1038-1042Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Laparoscopic liver surgery is evolving and the best technique for dividing the liver parenchyma is currently under debate. The aim of this study was to study different techniques during a full laparoscopic lobe resection, and determine the efficacy and risks of bleeding and gas embolism. METHODS: Sixteen pigs were randomized to two groups: group US underwent an operation with Ultracision shears (AutoSonix) and ultrasonic dissector (CUSA) and group VS with a vessel sealing system (Ligasure) and ultrasonic dissector. A left lobe resection was performed. Transesophageal endoscopic echocardiography (TEE) was used to detect gas emboli in the right side of the heart and pulmonary artery. The operations and TEE were recorded for later assessment. RESULTS: Compared with group VS, group US exhibited significantly more intraoperative bleeding (p = 0.02), a trend towards a longer operation time (p = 0.08), and a trend towards more embolization for grade I emboli. In total, 10 of 15 animals had emboli during the operation. CONCLUSIONS: This study showed that a laparoscopic left lobe resection can be performed with a combination of AutoSonix and CUSA as well as with Ligasure and CUSA instrumentation. In our hands, less bleeding was incurred with Ligasure than with AutoSonix.

  • 9.
    Eklund, Arne
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Rudberg, C.
    Leijonmarck, C-E.
    Rasmussen, Ib Christian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Spangen, L.
    Wickbom, G.
    Wingren, U.
    Montgomery, A.
    Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair2007In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 21, no 4, p. 634-640Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence. METHODS: This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique. RESULTS: A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group. CONCLUSION: The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

  • 10. Enochsson, L
    et al.
    Hellberg, A
    Rudberg, C
    Fenyö, G
    Gudbjartson, T
    Kullman, Eric
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Biomedicine and Surgery, Surgery. Östergötlands Läns Landsting, MKC-2, GE: Gastrokir.
    Ringqvist, I
    Sörensen, S
    Wenner, J
    Laparoscopic vs open appendectomy in overweight patients2001In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 15, no 4, p. 387-392Article in journal (Refereed)
    Abstract [en]

    Background: Laparoscopic appendectomy (LA) has been associated with a faster recovery and less postoperative pain than the open technique. However, few data are available on the clinical outcome of LA in overweight patients. Methods: A group of 106 patients with a body mass index (BMI) > 26.4, representing the upper quintile of 500 prospectively randomized patients, were included in the study. They were randomized to undergo either laparoscopic or open appendectomy (OA). Operating and anesthesia times, postoperative pain, complications, hospital stay, functional index (1 week postoperatively), sick leave, and time to full recovery were documented. Results: In OA, the operating time for overweight patients was significantly longer than that for patients in the normal weight range (40 vs 35 min, p < 0.05). In LA, there was no difference in operating time between the normal and overweight patients. Overweight patients who underwent LA had longer operating and anesthesia times than their OA counterparts (55 vs 40 min, p < 0.001, and 125 vs 100 min, p < 0.001, respectively). Postoperative pain was significantly greater in overweight patients who underwent OA than in those treated with the laparoscopic technique. Postoperative pain was also significantly greater in overweight patients subjected to OA than in patients of normal weight after 4 weeks, the clinical significance may, however, be of less importance since the values are low (0.26 vs 0.09, p < 0.05). There were no significant differences between the two operating techniques in terms of complications. Hospital stay was longer for overweight patients than for normal-weight patients undergoing OA (3.0 vs 2.0, p < 0.01). The functional index did not differ between any group of patients. Sick leave was longer for overweight patients who underwent OA than for normal-weight patients treated with the same technique (17 vs 13 days, p < 0.01). In the laparoscopic group, however, there were no differences between the overweight and normal-weight patients. Time to full recovery was greater in overweight patients subjected to OA than in the overweight patients in the LA group (22 vs 15 days, p < 0.001). Conclusion: In this study, overweight patients who were submitted to LA had less postoperative pain and a faster postoperative recovery than overweight patients who had OA. LA also abolished some of the negative effects that overweight had on operating time, hospital stay, and sick leave with the open technique. However, anesthesia and operating times were significantly longer in LA for both overweight patients and those with a normal BMI.

  • 11. Grong, Eivind
    et al.
    Kulseng, Bård
    Arbo, Ingerid Brænne
    Nord, Christoffer
    Umeå University, Faculty of Medicine, Umeå Centre for Molecular Medicine (UCMM).
    Eriksson, Maria
    Umeå University, Faculty of Medicine, Umeå Centre for Molecular Medicine (UCMM).
    Ahlgren, Ulf
    Umeå University, Faculty of Medicine, Umeå Centre for Molecular Medicine (UCMM).
    Mårvik, Ronald
    Sleeve gastrectomy, but not duodenojejunostomy, preserves total beta-cell mass in Goto-Kakizaki rats evaluated by three-dimensional optical projection tomography2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 2, p. 532-542Article in journal (Refereed)
    Abstract [en]

    Background In type 2 diabetes mellitus, there is a progressive loss of beta-cell mass. Bariatric surgery has in recent investigations showed promising results in terms of diabetes remission, but little is established regarding the effect of surgery on the survival or regeneration of pancreatic beta-cells. In this study, we aim to explore how bariatric surgery with its subsequent hormonal alterations affects the islets of Langerhans.

    Methods Twenty-four Goto-Kakizaki rats were operated with duodenojejunostomy (DJ), sleeve gastrectomy (SG) or sham operation. From the 38th week after surgery, body weight, fasting blood glucose, glycosylated hemoglobin, mixed meal tolerance with repeated measures of insulin, glucagon-like peptide 1, gastrin and total ghrelin were evaluated. Forty-six weeks after surgery, the animals were euthanized and the total beta-cell mass in all animals was examined by three-dimensional volume quantification by optical projection tomography based on the signal from insulin-specific antibody staining.

    Results Body weight did not differ between groups (Pg = 0.37). SG showed lower fasting blood glucose compared to DJ and sham (Pg = 0.037); HbA1c levels in SG were lower compared to DJ only (p\0.05). GLP-1 levels were elevated for DJ compared to SG and sham (Pg = 0.001), whereas gastrin levels were higher in SG compared to the two other groups (Pg = 0.002). Beta-cell mass was significantly greater in animals operated with SG compared to both DJ and sham (p = 0.036).

    Conclusion Sleeve gastrectomy is superior to duodenojejunostomy and sham operation when comparing the preservation of beta-cell mass 46 weeks after surgery in Goto-Kakizaki rats. This could be related to both the increased gastrin levels and the long-term improvement in glycemic parameters observed after this procedure.

  • 12.
    Haapamäki, Markku M
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindström, Monica
    Sandzén, Birger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Low-volume bowel preparation is inferior to standard 4 l polyethylene glycol2010In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 3, p. 897-901Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Four liters or more of orally taken polyethylene glycol solution (PEG) has proved to be an effective large-bowel cleansing method prior to colonoscopy. The problem has been the large volume of fluid and its taste, which is unacceptable to some examinees. We aimed to investigate the effectiveness of 2 l PEG combined with senna compared with 4 l PEG for bowel preparation.

    METHODS: The design was a single-center, prospective, randomized, investigator-blinded study with parallel assignment, in the setting of the Endoscopy Unit of Umeå University Hospital. Outpatients (n = 490) scheduled for colonoscopy were enrolled. The standard-volume arm received 4 l PEG, and the low-volume arm received 36 mg senna glycosides in tablets and 2 l PEG. The cleansing result (primary endpoint) was assessed by the endoscopist using the Ottawa score. The patients rated the subjective grade of ease of taking the bowel preparation. Analysis was on an intention-to-treat basis.

    RESULTS: There were significantly more cases with poor or inadequate bowel cleansing after the low-volume alternative with senna and 2 l PEG (22/203) compared with after 4 l PEG (8/196, p = 0.027). The low-volume alternative was better tolerated by the examinees: 119/231 rated the treatment as easy to take compared with 88/238 in the 4 l PEG arm (p = 0.001).

    CONCLUSIONS: 4 l PEG treatment is better than 36 mg senna and 2 l PEG as routine colonic cleansing before colonoscopy because of fewer failures.

  • 13.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Hedenström, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 7, p. 2302-2307Article in journal (Refereed)
    Abstract [en]

    Background

    The number of gastric bypass operations being preformed is increasing rapidly due to good weight loss and alleviation of co-morbidities in combination with low mortality and morbidity. Stomal ulcers are, however, a clinical problem after gastric bypass, giving patients discomfort, risk of bleeding or even perforation. To measure the acidity in the proximal jejunum, we adopted the wire-less pH-metry (BRAVO-system) developed for evaluating reflux esophagitis.

    Methods

    25 patients (4 men, median age 44 years, BMI 29.3) who had undergone RYGBP 4 years earlier were recruited. Twenty-one asymptomatic, non-PPI users and in addition, four symtomatic patients (ongoing or stopped PPI-treatment) were studied. The wire-less BRAVO-capsule was positioned at the level of the gastrojejunal anastomosis under visual control with the endoscope. pH was registered for up to 48 hours. Time with pH<4 was calculated. Two patients were studied with two capsules.

    Results

    Of the 25 recruited patients capsule placement was successful in all but 2 patients, and in 3 patients a constant neutral environment was seen before a premature loss of signal, indicating early loss of position, thus 20 successful measurements were made. The mean time of registration was 25.7 hours (6.1-47.4, n=20). In the 16 asymtomatic patients, median percentage of time with pH<4 at the gastrojejunostomy was 10.6% (range 0.4 -37.7%). When dividing the registration time in day (08.00-22.00) and night (22.00-06.00), the median percentage of time with pH<4 was 8.4 and 6.3, respectively, (p=0.08). The two double measurements gave similar results indicating consistency. No complications occurred.

    Conclusion

    Wire-less pH-measurements in the proximal jejunum after gastric bypass are feasible and safe. The acidity was significant (10.5% of the registration time) even in asymptomatic patients with small gastric pouches. The described method could be useful in evaluation of epigastralgia after gastric bypass and in appraisal of PPI treatment of stomal ulcer.

     

  • 14.
    Håkanson, B S
    et al.
    Center for Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet, Department for Clinical Science Intervention and Technology, Division of Surgery, Karolinska University Hospital, Stockholm.
    Thor, K B A
    Queen Sophia Hospital, Stockholm.
    Thorell, A
    Center for Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet, Department for Clinical Science Intervention and Technology, Division of Surgery, Karolinska University Hospital, Stockholm.
    Ljungqvist, Olle
    Center for Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet, Department for Clinical Science Intervention and Technology, Division of Surgery, Karolinska University Hospital, Stockholm.
    Open vs laparoscopic partial posterior fundoplication: A prospective randomized trial2007In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 21, no 2, p. 289-98Article in journal (Refereed)
    Abstract [en]

    Objective: This study compares outcomes following open and laparoscopic partial posterior fundoplication for gastroesophageal reflux disease concerning perioperative course, postoperative complications, symptomatic relief, recurrent disease, and the need for reinterventional surgery.

    Methods: A prospective randomized trial was performed. Pre- and postoperative testing included endoscopy, esophageal function testing, patient questionnaire, and clinical assessment. Patients were followed for three years.

    Materials: Ninety-three patients were randomized to open and 99 to laparoscopic surgery.

    Results: Complication rates were higher, and length of stay (LOS) [5 (3-36) vs 3 (1-12) days] and time off work [42 (12-76) vs 28 (0-108) days] was longer in the open group (p < 0.01). Early side effects and recurrences were more common (p < 0.05) in the laparoscopic group. One patient in the open group and 8 patients in the laparoscopic group required surgery for recurrent disease and 7 patients required surgery for incisional hernias after open surgery. Overall, at one and three years, there were no differences in patient-assessed satisfactory outcome (93.5/93.5 vs 88.8/90.8%) or reflux control (p = 0.53) between the open and laparoscopic groups.

    Conclusions: The finding of fewer general complications, shorter length of stay and recovery, similar need for reoperations, and comparable 3-year outcomes, makes the laparoscopic approach the primary choice when considering surgical options for the treatment of gastroesophageal reflux disease (GERD).

  • 15. Jersenius, U.
    et al.
    Fors, Diddi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Arvidsson, Dag
    Laparoscopic parenchymal division of the liver in a porcine model: comparison of the efficacy and safety of three different techniques2007In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 21, no 2, p. 315-320Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Bleeding is a known and CO2 embolization a suggested risk factor for increased morbidity after laparoscopic liver resection. Devices for laparoscopic liver parenchymal transection must be evaluated for safety in this context. METHOD: Twelve piglets underwent laparoscopic surgery during CO2 pneumoperitoneum, each animal receiving three 6 cm long transections into the liver parenchyma made with ultrasonic dissector, ultrasonic shears and vessel sealing system, respectively. Endpoints were bleeding, operation time and gas embolization. The transections and embolization events, evaluated with transesophageal echocardiography, were video recorded. Bleeding and embolization were also assessed on video tapes and operating time measured. Arterial blood gases were recorded on line. RESULTS: The ultrasonic dissector was least advantageous in terms of bleeding and operation time. Gas embolization was more frequent with the vessel sealing system than with the ultrasonic dissector and ultrasonic shears. During two episodes of gas embolization, pCO2 increased and pO2 and pH decreased. CONCLUSIONS: Use of all three devices is feasible. Bleeding and operation time are greatest with the ultrasonic dissector. Gas embolization occurs during transection, though in most instances it is completely harmless. Laparoscopic liver surgery with these techniques used may pose a risk of gas embolization with clinical implications. Monitoring for such events is probably to be recommended.

  • 16.
    Langerth, Ann
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Isaksson, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Karlson, Britt-Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Urdzik, Jozef
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Linder, Stefan
    Karolinska Inst, Karolinska Univ Hosp, Ctr Digest Dis, Div Surg,CLINTEC, Stockholm, Sweden.
    ERCP‑related perforations: a population‑based study of incidence,mortality, and risk factors2020In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 34, p. 1939-1947Article in journal (Refereed)
    Abstract [en]

    Background: Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study.

    Methods: Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1-3) groups. Furthermore, fatal group patients' records were reviewed.

    Results: Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8-21.6), age over 80 years (OR 3.8, 95% CI 2.0-7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1-7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1-3 centers mortality was higher (45% vs. 21%, p = 0.024).

    Conclusions: ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.

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  • 17. Lindberg, F
    et al.
    Bergqvist, D
    Björck, M
    Rasmussen, I
    Renal hemodynamics during carbon dioxide pneumoperitoneum: an experimental study in pigs.2003In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 17, no 3, p. 480-4Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic living donor nephrectomy is increasingly being performed, although the effects of carbon dioxide pneumoperitoneum (CO2 PP) on renal function and hemodynamics and the levels of vasopressin are not well studied.

    METHODS: Renal blood flow, renal venous pressure, urine output, and vasopressin concentrations in renal venous blood were measured in pigs subjected to 12 mmHg of CO2 PP for 150 min.

    RESULTS: Renal blood flow was decreased at induction of PP and increased during the first 30 min after exsufflation. Renal venous pressure was increased during PP. There was indirect evidence of a decrease in urine output during PP. No changes in renal venous vasopressin concentrations were seen.

    CONCLUSION: A CO2 PP of 12 mmHg causes changes in renal hemodynamics and urine output. No changes in vasopressin levels were seen in this pig model, suggesting that other explanations for the observed changes must be sought.

  • 18. Lindberg, F
    et al.
    Bergqvist, D
    Rasmussen, I
    Haglund, U
    Hemodynamic changes in the inferior caval vein during pneumoperitoneum. An experimental study in pigs.1997In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 11, no 5, p. 431-7Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic procedures of increasing difficulty and duration are becoming more and more common. This may cause significant challenges to the circulatory system and possibly influence thrombogenicity.

    METHODS: Experimental study of carbon dioxide pneumoperitoneum in pigs.

    RESULTS: Inferior caval vein blood flow remained unchanged, whereas inferior caval vein pressure increased during pneumoperitoneum. Inferior caval vein, pulmonary, and systemic vascular resistance increased during pneumoperitoneum and remained increased after exsufflation.

    CONCLUSIONS: Pneumoperitoneum leads to an increased inferior caval vein pressure, which could cause a dilation of peripheral veins. The similar patterns of vascular resistance in the inferior caval vein, pulmonary artery, and systemic arteries (a gradual increase remaining elevated after exsufflation) suggest a common humoral factor or increased sympathetic nerve activity.

  • 19.
    Lindberg, F.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Rasmussen, Ib Christian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Current use of thromboembolism prophylaxis for laparoscopic cholecystectomy patients in Sweden2005In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 19, no 3, p. 386-388Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The need for thromboembolism (TE) prophylaxis during laparoscopic surgery is not well established. The aim of this study was to investigate current TE prophylaxis in patients undergoing laparoscopic cholecystectomy (LC) in Sweden. METHODS: Mail questionnaire to all Surgical Departments in Sweden about the current use of thromboembolism prophylaxis in patients undergoing laparoscopic cholecystectomy. RESULTS: The response rate was 78 of 80 departments of surgery (98%). Seventy reported performing LC. Thirty-six percent used thromboembolism prophylaxis in all patients, 17% in most, 9% in half their patients and 39% only rarely. The current use of thromboembolism prophylaxis ranged from low-molecular-weight heparin for 7 days + stockings in all patients to no prophylaxis at all in the majority of patients. CONCLUSIONS: The use of thromboembolism prophylaxis in LC patients is highly variable, even in the small and homogenous country of Sweden. Further studies concerning the risk of TE complications after laparoscopic surgery are warranted.

  • 20. Lindberg, F
    et al.
    Rasmussen, I
    Siegbahn, A
    Bergqvist, D
    Coagulation activation after laparoscopic cholecystectomy in spite of thromboembolism prophylaxis.2000In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 14, no 9, p. 858-61Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to determine whether laparoscopic cholecystectomy (LC), in spite of its minimally invasive nature, causes coagulation activation.

    METHODS: Sixty-four patients undergoing LC were included prospectively. All received either dextran or low-molecular-weight heparin (LMWH). Blood samples taken the morning of the operation and the following morning were analyzed for TAT, FM, fragment 1+2, tPA, PAI-1, vWf, D-dimer, Hb, hematocrit, and APC resistance.

    RESULTS: Significant increases in TAT, FM, fragment 1+2, and D-dimer were seen, whereas APC resistance, Hb, and hematocrit decreased significantly. Dextran led to a decrease in vWf and no change in tPA, whereas LMWH led to an increase in both these parameters.

    CONCLUSIONS: Laparoscopic cholecystectomy causes coagulation activation. There are differences in the response between patients receiving dextran and LMWH as thromboembolism prophylaxis. Since most patients are discharged the day after the operation, there could be practical as well as theoretical advantages to using dextran.

  • 21.
    Ljungdahl, Mikael
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial2006In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 20, no 8, p. 1248-1251Article in journal (Refereed)
    Abstract [en]

    Background: Percutaneous endoscopic gastrostomy (PEG) has increasingly replaced surgical gastrostomy (SG) as the primary procedure for the long-term nutrition of patients with swallowing disorders. This prospective randomized study compares PEG with SG in terms of effectiveness and safety. Methods: This study enrolled 70 patients with swallowing disorders, mainly attributable to neurologic impairment. All the patients, eligible for both techniques, were randomized to PEG (pull method) or SG. The groups were comparable in terms of age, body mass index, and underlying diseases. Complications were reported 7 and 30 days after the operative procedure. Results: The procedures were successfully completed for all the patients. The median operative time was 15 min for PEG and 35 min for SG (p < 0.001). The rate of complications was lower for PEG (42.9%) than for SG (74.3%; p < 0.01). The 30-day mortality rates were 5.7% for PEG and 14.3% for SG (nonsignificant difference). Conclusion: The findings show PEG to be an efficient method for gastrostomy tube placement with a lower complication rate than SG. In addition, PEG is faster to perform and requires fewer medical resources. The authors consider PEG to be the primary procedure for gastrostomy tube placement.

  • 22.
    Lundberg, Owe
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kristoffersson, Ander
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Pneumoperitoneum impairs blood flow and augments tumor growth in the abdominal wall.2004In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 18, no 2, p. 293-296Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite several clinical and experimental studies, the mechanisms behind the development of port site metastases in laparoscopic surgery have remained largely unknown. The current study was designed to investigate the effect of pneumoperitoneum on blood flow in the abdominal wall and its possible effects on tumor growth at this site. METHODS: A total of 40 Wistar Fu rats had a laser Doppler probe placed on their left rectus muscle and a suspension of 50,000 adenocarcinoma cells was injected into their right rectus muscle. The experimental group (n = 20) was insufflated with air at 10 mmHg for 45 min while abdominal blood flow was registered before and during insufflation and after exsufflation. The control group (n = 20) was not insufflated but the blood flow was recorded in the same manner. After 9 days, all animals were killed and the occurrence of tumor was observed. The tumors were analyzed with respect to weight and volume. RESULTS: The insufflation caused an 82% reduction in blood flow in the experimental group (p < 0.001). No reduction in blood flow was registered in the control group. Tumor nodules developed significantly more often in the insufflated group (20/20) compared to the controls (14/20) (p = 0.016). Tumor weight (p = 0.003) and volume (p < 0.001) were significantly increased in the insufflated group. CONCLUSIONS: Pneumoperitoneum seems to enhance tumor growth. It also causes a significant reduction in blood flow in the abdominal wall, which may contribute to the increased susceptibility of tumor take.

  • 23.
    Lundberg, Owe
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kristoffersson, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Reduction of abdominal wall blood flow by clamping or carbon dioxide insufflation increases tumor growth in the abdominal wall: an experimental study in rats.2005In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 19, no 5, p. 720-723Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: We have previously demonstrated that there is a reduction of blood flow in the abdominal wall in rats insufflated with air concomitant with an increase in tumor growth. The present study was designed to examine whether a reduction of blood flow achieved by clamping or insufflation with carbon dioxide (CO(2)) would increase tumor growth in the abdominal wall. METHODS: In the first part of the experiments, laser Doppler blood flow of both rectus muscles was measured in 16 Wistar Fu rats. The left rectus muscle was clamped to reduce blood flow, and 5 x 10(4) adenocarcinoma cells were injected into both rectus muscles. Clamping was maintained for 45 min. In the second part, 22 rats had 5 x 10(4) adenocarcinoma cells injected into the rectus muscle and blood flow was measured. The experimental group (n = 11) was insufflated with CO(2) at 10 mmHg for 45 min; the control group (n = 11) was not insufflated. After 9 days, tumor weight and volume were analyzed. RESULTS: Clamping caused a 69% reduction of blood flow (p < 0.001), whereas no reduction was registered on the nonclamped side. Tumor weight (p = 0.028) and volume (p = 0.030) were increased on the clamped side. The insufflation of CO(2) caused a 71% reduction of blood flow, whereas no reduction was registered in the control group. Tumor weight (p = 0.006) and volume (p = 0.006) were increased in the insufflated group. CONCLUSION: Clamping, as well as CO(2) insufflation, causes a significant reduction of blood flow in the abdominal wall, which seems to increase tumor growth at the same site.

  • 24. Noel, Rozh
    et al.
    Enochsson, Lars
    Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
    Swahn, Fredrik
    Löhr, Matthias
    Nilsson, Magnus
    Permert, Johan
    Arnelo, Urban
    A 10-year study of rendezvous intraoperative endoscopic retrograde cholangiography during cholecystectomy and the risk of post-ERCP pancreatitis2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 7, p. 2498-2503Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Rendezvous intraoperative endoscopic retrograde cholangiography (RV-IOERC), also called guidewire-facilitated IOERC, is one of the single-stage options available for managing common bile duct stones (CBDS) during laparoscopic cholecystectomy. The objective of this study is to investigate procedure-related complications in IOERC patients and stone clearance.

    METHODS: All patients who underwent IOERC between January 2000 and December 2009 were identified from the local registry of Karolinska University Hospital in Huddinge. Medical charts and ERC reports were studied, and descriptive statistics were obtained. Outcomes were procedure-related complications, especially post-ERCP pancreatitis (PEP), stone clearance, and mortality.

    RESULTS: 307 patients were identified. In 264 of the patients, the rendezvous cannulation technique was successful (86 %); in the remaining 43 patients, conventional cannulation technique was necessary. In total, PEP occurred in seven patients (2.28 %). One of the PEP patients was in the rendezvous cannulated group (0.37 %), whereas six patients developed PEP in the nonrendezvous group (13.95 %, p < 0.001). The primary stone clearance rate was 88.27 % (271/307). There was no mortality within 90 days in the series.

    CONCLUSIONS: IOERC with RV cannulation technique for management of CBDS during laparoscopic cholecystectomy has a low PEP rate and a high stone clearance rate, making it a safe and feasible method for removing CBDS. However, the technique requires logistics to perform IOERC in the operating theater. The present data suggest that IOERC with RV cannulation is superior to conventional cannulation with respect to risk of PEP.

  • 25.
    Odeberg, S.
    et al.
    Dept. Anesthesia and Intensive Care, Huddinge University Hospital, Huddinge, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Huddinge University Hospital, Huddinge, Sweden.
    Svenberg, Torgny E.
    Department of Surgery, Karolinska Hospital,6 Stockholm, Sweden.
    Sollevi, Alf
    Dept. Anesthesia and Intensive Care, Huddinge University Hospital, Huddinge, Sweden.
    Lack of neurohumoral response to pneumoperitoneum for laparoscopic cholecystectomy1998In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 12, no 10, p. 1217-1223Article in journal (Refereed)
    Abstract [en]

    Background: Pneumoperitoneum (PP) for laparoscopic surgery induces prompt changes in circulatory parameters. The rapid onset of these changes suggests a reflex origin, and the present study was undertaken to evaluate whether release of vasopressor substances could be responsible for these alterations. The influence of two different anesthesia techniques was also evaluated. Methods: American Society of Anesthesiologists (ASA) class I patients, scheduled for laparoscopic cholecystectomy, were investigated. The first group (n = 10) was anesthetized intravenously. The second group (n = 6) had inhalation anesthesia. Plasma vasopressin, catecholamines, and plasma renin activity were investigated as neurohumoral vasopressor markers of circulatory stress. The general stress response to surgery was assessed by analysis of plasma cortisol. Results: Induction of pneumoperitoneum caused no apparent activation of vasopressor substances, although several hemodynamic parameters responded promptly. Conclusion: The hemodynamic alterations, seen at the establishment of PP during stable anesthesia, cannot be explained by elevation of vasopressor substances in circulating blood.

  • 26.
    Oussi, Ninos
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Surg, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Loukas, Constantinos
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Kjellin, Ann
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Surg, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Lahanas, Vasileios
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Georgiou, Konstantinos
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Henningsohn, Lars
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Urol, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Felländer-Tsai, Li
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Orthoped & Biotechnol, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Georgiou, Evangelos
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Enochsson, Lars
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Surg, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.; Umeå Univ, Dept Surg & Perioperat Sci, Div Surg, Umeå.; Umeå Univ, Dept Surg & Perioperat Sci, Div Surg, Luleå.
    Video analysis in basic skills training: a way to expand the value and use of BlackBox training?2018In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 1, p. 87-95Article in journal (Refereed)
    Abstract [en]

    Background

    Basic skills training in laparoscopic high-fidelity simulators (LHFS) improves laparoscopic skills. However, since LHFS are expensive, their availability is limited. The aim of this study was to assess whether automated video analysis of low-cost BlackBox laparoscopic training could provide an alternative to LHFS in basic skills training.

    Methods

    Medical students volunteered to participate during their surgical semester at the Karolinska University Hospital. After written informed consent, they performed two laparoscopic tasks (PEG-transfer and precision-cutting) on a BlackBox trainer. All tasks were videotaped and sent to MPLSC for automated video analysis, generating two parameters (Pl and Prtcl_tot) that assess the total motion activity. The students then carried out final tests on the MIST-VR simulator. This study was a European collaboration among two simulation centers, located in Sweden and Greece, within the framework of ACS-AEI.

    Results

    31 students (19 females and 12 males), mean age of 26.2 ± 0.8 years, participated in the study. However, since two of the students completed only one of the three MIST-VR tasks, they were excluded. The three MIST-VR scores showed significant positive correlations to both the Pl variable in the automated video analysis of the PEG-transfer (RSquare 0.48, P < 0.0001; 0.34, P = 0.0009; 0.45, P < 0.0001, respectively) as well as to the Prtcl_tot variable in that same exercise (RSquare 0.42, P = 0.0002; 0.29, P = 0.0024; 0.45, P < 0.0001). However, the correlations were exclusively shown in the group with less PC gaming experience as well as in the female group.

    Conclusions

    Automated video analysis provides accurate results in line with those of the validated MIST-VR. We believe that a more frequent use of automated video analysis could provide an extended value to cost-efficient laparoscopic BlackBox training. However, since there are gender-specific as well as PC gaming experience differences, this should be taken in account regarding the value of automated video analysis.

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  • 27. Oussi, Ninos
    et al.
    Loukas, Constantinos
    Kjellin, Ann
    Lahanas, Vasileios
    Georgiou, Konstantinos
    Henningsohn, Lars
    Felländer-Tsai, Li
    Georgiou, Evangelos
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Video analysis in basic skills training: a way to expand the value and use of BlackBox training?2018In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 1, p. 87-95Article in journal (Refereed)
    Abstract [en]

    Background: Basic skills training in laparoscopic high-fidelity simulators (LHFS) improves laparoscopic skills. However, since LHFS are expensive, their availability is limited. The aim of this study was to assess whether automated video analysis of low-cost BlackBox laparoscopic training could provide an alternative to LHFS in basic skills training.

    Methods: Medical students volunteered to participate during their surgical semester at the Karolinska University Hospital. After written informed consent, they performed two laparoscopic tasks (PEG-transfer and precision-cutting) on a BlackBox trainer. All tasks were videotaped and sent to MPLSC for automated video analysis, generating two parameters (Pl and Prtcl_tot) that assess the total motion activity. The students then carried out final tests on the MIST-VR simulator. This study was a European collaboration among two simulation centers, located in Sweden and Greece, within the framework of ACS-AEI.

    Results: 31 students (19 females and 12 males), mean age of 26.2 +/- 0.8 years, participated in the study. However, since two of the students completed only one of the three MIST-VR tasks, they were excluded. The three MIST-VR scores showed significant positive correlations to both the Pl variable in the automated video analysis of the PEG-transfer (RSquare 0.48, P < 0.0001; 0.34, P = 0.0009; 0.45, P < 0.0001, respectively) as well as to the Prtcl_tot variable in that same exercise (RSquare 0.42, P = 0.0002; 0.29, P = 0.0024; 0.45, P < 0.0001). However, the correlations were exclusively shown in the group with less PC gaming experience as well as in the female group.

    Conclusion: Automated video analysis provides accurate results in line with those of the validated MIST-VR. We believe that a more frequent use of automated video analysis could provide an extended value to cost-efficient laparoscopic BlackBox training. However, since there are gender-specific as well as PC gaming experience differences, this should be taken in account regarding the value of automated video analysis.

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  • 28.
    Persson, Jan
    et al.
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Surg,Inst Clin Sci, S-41345 Gothenburg, Sweden.
    Smedh, Ulrika
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Surg,Inst Clin Sci, S-41345 Gothenburg, Sweden.
    Johnsson, Åse
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Radiol,Inst Clin Sci, Gothenburg, Sweden.
    Ohlin, Bo
    Blekinge Hosp, Dept Surg, Karlskrona, Sweden.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Nilsson, Magnus
    Karolinska Inst, Karolinska Univ Hosp, Div Surg, Dept Surg Gastroenterol,CLINTEC, Stockholm, Sweden.
    Lundell, Lars
    Karolinska Inst, Karolinska Univ Hosp, Div Surg, Dept Surg Gastroenterol,CLINTEC, Stockholm, Sweden.
    Sund, Berit
    Karolinska Inst, Karolinska Univ Hosp, Div Surg, Dept Surg Gastroenterol,CLINTEC, Stockholm, Sweden.
    Johnsson, Erik
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Surg,Inst Clin Sci, S-41345 Gothenburg, Sweden.
    Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial.2017In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 31, no 10, p. 4025-4033Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Stent migration is a significant clinical problem in palliation of malignant strictures in the esophagus and gastro-esophageal junction (GEJ). We have compared a newer design of a fully-covered stent to a widely used semi-covered stent using migration >20 mm as the primary outcome variable. Effects on dysphagia, quality of life (QoL) and re-intervention frequency were also investigated.

    METHODS: Patients with dysphagia due to non-curable esophagus/GEJ cancer were randomized to receive either a more recent design of a fully-covered stent (n = 48) or a conventional semi-covered stent (n = 47). Chest x-ray, dysphagia and QoL were studied at baseline, one week, four weeks and three months thereafter.

    RESULTS: There were no significant differences either in stent migration distance or in the migration frequency. Stent migration during the total study period occurred in 37.2 % in the semi-covered group compared to 20.0 % for the fully-covered group. Dysphagia was measured with Watson and Ogilvie scores and with the dysphagia module in the QoL scale (QLQ-OG25). On average, there was a tendency to better dysphagia relief for the fully-covered design as scored with the two latter dysphagia instruments (p= 0.081 and p= 0.067) at three months and towards more re-interventions in the semi-covered group (p= 0.083).

    CONCLUSION: In spite of its somewhat lower intrinsic radial force, the fully-covered stent was comparable to the conventional semi-covered stent with regard to stent migration. The data further suggest a potential benefit of the fully-covered stent in improving dysphagia in patients with longer life expectancy.

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  • 29. Sandbu, R
    et al.
    Birgisdottir, B
    Arvidsson, D
    Sjöstrand, U
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Optimal positive end-expiratory pressure (PEEP) settings in differential lung ventilation during simultaneous unilateral pneumothorax and laparoscopy: an experimental study in pigs.2001In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 15, no 12, p. 1478-83Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A combined thoraco-laparoscopic technique for esophageal resection is technically possible, but it requires special attention to ventilation. The positive insufflation pressure normally used in laparoscopy will, when communication between thorax and abdomen is established, create a pneumothorax.

    METHODS: We performed an experimental study of differential lung ventilation with different levels of positive end-expiratory pressure (PEEP) settings during thoraco-laparoscopy in anesthetized pigs.

    RESULTS: Positive pressure insufflation of carbon dioxide (CO2) resulted in elevated pulmonary capillary wedge pressure, hypercarbia, and respiratory acidosis. Hypoxemia, however, developed only at lower settings of PEEP. Heart rate, mean arterial pressure, and cardiac output remained relatively stable.

    CONCLUSION: Pneumopleuroperitoneum under positive CO2 insufflation pressure had adverse effects on blood gases. Hypercarbia, respiratory acidosis, and hypoxemia were early manifestations that occurred even in the presence of hemodynamic stability. The application of PEEP equal to or above CO2 insufflation pressure improved blood gases; in particular, the hypoxia could be avoided. No beneficial effects of differential lung ventilation were documented.

  • 30. Schölin, Johnna
    et al.
    Buunen, Mark
    Hop, Wim
    Bonjer, Jaap
    Anderberg, Bo
    Cuesta, Miguel
    Delgado, Salvadora
    Ibarzabal, Ainitze
    Ivarsson, Marie-Louise
    Janson, Martin
    Lacy, Antonio
    Lange, Johan
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Skullman, Stefan
    Haglind, Eva
    Bowel obstruction after laparoscopic and open colon resection for cancer: results of 5 years of follow-up in a randomized trial2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 12, p. 3755-3760Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Postoperative bowel obstruction caused by intra-abdominal adhesions occurs after all types of abdominal surgery. It has been suggested that the laparoscopic technique should reduce the risk for adhesion formation and thus for postoperative bowel obstruction. This study was designed to compare the incidence of bowel obstruction in a randomized trial where laparoscopic and open resection for colon cancer was compared.

    METHODS: A retrospective analysis was performed, collecting data of episodes of bowel obstruction with or without surgery. Only episodes treated in the hospital where the index surgery took place were included. Data for 786 patients were collected for the 5-year period after cancer surgery.

    RESULTS: Baseline characteristics for the evaluated laparoscopic (n = 383) and open (n = 403) groups were comparable. The cumulative obstruction percentages at 5 years for the open and laparoscopic groups were 6.5 and 5.1% respectively and did not significantly differ from each other. Tumor stage seemed to influence the risk for bowel obstruction: 2.8% in stage I, 6.6% in stage II, and 7% in stage III, but the differences were not significant.

    CONCLUSIONS: This analysis does not support the hypothesis that laparoscopy leads to fewer episodes of bowel obstruction compared with open surgery.

  • 31. Siegel, R.
    et al.
    Cuesta, M. A.
    Targarona, E.
    Bader, F. G.
    Morino, M.
    Corcelles, R.
    Lacy, A. M.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Haglind, E.
    Bujko, K.
    Bruch, H. P.
    Heiss, M. M.
    Eikermann, M.
    Neugebauer, E. A. M.
    Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 8, p. 2423-2440Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

    METHODS:

    An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

    RESULTS:

    Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

    CONCLUSIONS:

    Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

  • 32.
    Sima, Eduardo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gastrointestinal symptoms, weight loss and patient satisfaction 5 years after gastric bypass: a study of three techniques for the gastrojejunal anastomosis.2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 4, p. 1553-1558Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The optimal operative technique in gastric bypass (RYGB) is still under debate. We have studied patient-reported gastrointestinal symptoms and weight loss 5 years after RYGB performed with three different stapling techniques for the gastrojejunal anastomosis (GJ).

    METHODS: Out of 593 patients operated with RYGB, 489 patients [80.2 % women, body mass index (BMI) 44.9 (33-68) kg/m(2)] answered our 5-year follow-up questionnaire concerning gastrointestinal symptoms (vomiting, reflux, dumping, abdominal pain or diarrhea), weight loss, need for postoperative endoscopic interventions and overall satisfaction with the procedure. We compared the results for three different GJ techniques: linear stapler (LS, n = 103), 21-mm circular stapler (C21, n = 88) and 25-mm circular stapler (C25, n = 298).

    RESULTS: Dumping was the most commonly reported symptom (14.1 % of all patients on a weekly to daily basis), however, less frequently reported in the C25 group (p < 0.05). Vomiting, prevalent in 2.9 % of all patients, was more frequently reported in the C21 group (p < 0.01). No group consistently showed greater weight loss compared to the other two groups. A higher incidence of endoscopic dilatations due to strictures was reported in the C21 group (12.5 % compared to 4.5 % of all patients, p < 0.05). Overall patient satisfaction was high (88 %).

    CONCLUSION: Our data suggest that the technique for the construction of the GJ in RYGB affects gastrointestinal symptoms 5 years postoperatively. The difference is moderate but indicates that a narrow GJ results in increased frequency of vomiting and need for endoscopic interventions without improving the weight result.

  • 33. Soreide, Jon Arne
    et al.
    Karlsen, Lars Normann
    Sandblom, Gabriel
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Endoscopic retrograde cholangiopancreatography (ERCP): lessons learned from population-based national registries: a systematic review2019In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 33, no 6, p. 1731-1748Article, review/survey (Refereed)
    Abstract [en]

    Background: Endoscopic retrograde cholangiopancreatography (ERCP) was introduced more than four decades ago as a diagnostic tool for biliary and pancreatic diseases. Currently, ERCP is mainly used as a therapeutic approach to relieve biliary or pancreatic duct obstruction. Clinical practice has been based on a few large reports and some randomized controlled trials. These data are valuable and important, but the external validity of these reports is limited. Implementation into routine practice should be balanced with the knowledge that these studies were conducted under very specific circumstances. This review was undertaken to describe ERCP results from population-based national registries recorded during routine clinical practice.

    Methods: A systematic literature search of the electronic databases Medline Ovid and Embase was conducted. Eligible papers were selected and data were recorded according to the PRISMA criteria.

    Results: Thirty-one studies were included: 15 true national population-based and 16 population-level studies. Most studies originated from countries with a governmental public health care system. At least three-quarters of the ERCP procedures are currently therapeutic, and the technical success rate is high (>90%). The postprocedure 30-day mortality rate ranged between 1 and 5% and was strongly correlated with older age, male sex, emergency admission, and noncancer comorbidities, but exhibited a lower correlation with the annual ERCP volume. Patients with primary sclerosing cholangitis or liver cirrhosis should receive particular attention. The risk of developing a bile duct, liver, or pancreas malignancy after ERCP tended to increase, but endoscopic sphincterotomy did not affect this risk.

    Conclusion: ERCP is currently mainly used as a therapeutic approach, and the results are generally likely to improve patients' conditions. A nationwide registry enables better monitoring of routine clinical practice. The collection of valuable information from routine clinical practice in population-based databases may help to improve patient care from best evidence to best practice.

  • 34.
    Strom, P.
    et al.
    Ström, P., Center for Surgical Sciences, Karolinska Institutet, Huddinge University Hospital, SE-141 86 Stockholm, Sweden.
    Kjellin, A.
    Center for Surgical Sciences, Karolinska Institutet, Huddinge University Hospital, SE-141 86 Stockholm, Sweden.
    Hedman, L.
    Department of Psychology, Skill Acquisition Laboratory, Umeå University, SE-901, 87 Umeå, Sweden.
    Johnson, Ericka
    Linköping University, Faculty of Arts and Sciences. Linköping University, The Tema Institute, Technology and Social Change.
    Wredmark, T.
    Center for Surgical Sciences, Karolinska Institutet, Huddinge University Hospital, SE-141 86 Stockholm, Sweden.
    Fellander-Tsai, L.
    Felländer-Tsai, L., Center for Surgical Sciences, Karolinska Institutet, Huddinge University Hospital, SE-141 86 Stockholm, Sweden.
    Validation and learning in the Procedicus KSA virtual reality surgical simulator: Implementing a new safety culture in medical school2003In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 17, no 2, p. 227-231Article in journal (Refereed)
    Abstract [en]

    Background: Advanced simulator training within medicine is a rapidly growing field. Virtual reality simulators are being introduced as cost-saving educational tools, which also lead to increased patient safety. Methods: Fifteen medical students were included in the study. For 10 medical students performance was monitored, before and after 1 h of training, in two endoscopic simulators (the Procedicus KSA with haptic feedback and anatomical graphics and the established MIST simulator without this haptic feedback and graphics). Five medical students performed 50 tests in the Procedicus KSA in order to analyze learning curves. One of these five medical students performed multiple training sessions during 2 weeks and performed more than 300 tests. Results: There was a significant improvement after 1 h of training regarding time, movement economy, and total score. The results in the two simulators were highly correlated. Conclusion: Our results show that the use of surgical simulators as a pedagogical tool in medical student training is encouraging. It shows rapid learning curves and our suggestion is to introduce endoscopic simulator training in undergraduate medical education during the course in surgery when motivation is high and before the development of "negative stereotypes" and incorrect practices.

  • 35. Strömberg, Cecilia
    et al.
    Arnelo, Urban
    Enochsson, Lars
    Löhr, Matthias
    Nilsson, Magnus
    Possible mortality reduction by endoscopic sphincterotomy during endoscopic retrograde cholangiopancreatography: a population-based case-control study.2012In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 26, no 5, p. 1369-76Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for young patients, but ERCP and endoscopic sphincterotomy in particular are reported to be associated with increased complication and mortality rates. This study aimed to calculate mortality and to identify risk factors for death within 90 days after ERCP for nonmalignant disease.

    METHODS: From the Swedish Hospital Discharge Registry, the authors identified all individuals in Stockholm County who had undergone in-patient ERCP during 1990-2003. Among these individuals, they excluded those recorded in the Swedish Cancer Registry as having a diagnosis of malignancy in the liver, pancreas, or bile ducts. Cases, defined as patients who had died within 90 days after the procedure, were identified by cross-linkage to the causes of death registry. Control subjects were randomly sampled from the same cohort. The medical records were studied to discern risk factors for death after ERCP.

    RESULTS: The mortality rate was 1.6%. Advanced age, severe comorbidity, high complexity of the procedure, and occurrence of a complication were associated with death within 90 days, whereas a previous cholecystectomy or the simultaneous performance of an endoscopic sphincterotomy reduced the risk.

    CONCLUSIONS: Old age and comorbidity are the main risk factors for death after ERCP, but a complex procedure or the occurrence of a complication also seems to increase short-term mortality. The performance of a sphincterotomy may reduce the risk of death, possibly by facilitating adequate drainage. A previous cholecystectomy also may decrease the risk of death after ERCP.

  • 36. Tempe, Fredrik
    et al.
    Janes, Arthur
    Cengiz, Yucel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cost analysis comparing ultrasonic fundus-first and conventional laparoscopic cholecystectomy using electrocautery2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 8, p. 2856-2859Article in journal (Refereed)
    Abstract [en]

    Costs associated with laparoscopic fundus-first cholecystectomy using ultrasonic dissection versus a conventional laparoscopic cholecystectomy has not been compared. Adult patients subjected to elective laparoscopic cholecystectomy between June 2002 and March 2004 were randomized to either an ultrasonic fundus-first dissection or dissection from the triangle of Calot with electrocautery. Differences in direct and indirect costs related to either technique were studied. The duration of the operation and hospitalization was longer when dissection was with the conventional technique. With the ultrasonic fundus-first technique, the direct cost was 1,190 SEK lower, and the total cost, taking also the cost for sick leave into account, was 5,370 SEK lower. Both direct and indirect costs are lower with a laparoscopic fundus-first cholecystectomy using ultrasonic dissection than conventional laparoscopic cholecystectomy using electrocautery.

  • 37.
    Veldkamp, R
    et al.
    Department of General Surgery, Erasmus MC.
    Gholghesaei, M
    Department of General Surgery, Erasmus MC.
    Bonjer, HJ
    Department of General Surgery, Erasmus MC.
    Meijer, DW
    Department of General Surgery, Erasmus MC.
    Buunen, M
    Department of General Surgery, Erasmus MC.
    Jeekel, J
    Department of General Surgery, Erasmus MC.
    Anderberg, B
    Linköping University, Department of Biomedicine and Surgery. Linköping University, Faculty of Health Sciences.
    Cuesta, MA
    VU Medical Center, Amsterdam.
    Cuschieri, A
    Ninewells Hospital and Medical School.
    Fingerhut, A
    Centre Hospitalier Intercommunal, Polssy, France.
    Fleshman, JW
    Washington University.
    Guillou, PJ
    St. Jamess University Hospital.
    Haglind, E
    Sahlgrenska University Hospital.
    Himpens, J
    Saint Blasius General Hospital.
    Jacobi, CA
    Humboldt University of Berlin.
    Jakimowicz, JJ
    Department of General Surgery, Erasmus MC.
    Koeckerling, F
    Hannover Hospital.
    Lacy, AM
    Hospital Clinic i Provincial, Barcelona.
    Lezoche, E
    University of Rome.
    Monson, JR
    The University of Hull.
    Morino, M
    University of Turin.
    Neugebauer, E
    University of Cologne.
    Wexner, SD
    Cleveland Clinic Florida.
    Whelan, RL
    Columbia University College of Physicians and Surgeons.
    Laparoscopic resection of colon cancer - Consensus of the European Association of Endoscopic Surgery (EAES)2004In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 18, no 8, p. 1163-1185Article, review/survey (Refereed)
    Abstract [en]

    Background: The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002. Methods: A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer. Results: Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is less than1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery. Conclusion: Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

  • 38. Videhult, Per
    et al.
    Sandblom, Gabriel
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Rasmussen, Ib Christian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    How reliable is intraoperative cholangiography as a method for detecting common bile duct stones?: A prospective population-based study on 1171 patients2009In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 23, no 2, p. 304-12Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although intraoperative cholangiography (IOC) is a widely used method for detecting common bile duct stones (CBDS), its accuracy has not been fully evaluated in large nonselected patient samples. The purpose of this study was to assess the sensitivity, specificity and predictive value of dynamic IOC regarding its ability to diagnose CBDS in a population-based setting, and to assess the morbidity associated with the investigation. METHODS: All patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala in Sweden, a county with a population of 302,000 in December 2004, were registered prospectively. The outcome of cholangiography was validated against the postoperative clinical course. RESULTS: 1171 patients were registered, and among these IOC was performed in 1117 patients (95%). Common bile duct stones were found in 134 patients (11%). One perforation of the common bile duct caused by the IOC catheter was recorded. Sensitivity was 97%, specificity 99%, negative predictive value 99%, positive predictive value 95%, and overall accuracy 99%. In 7 of the 134 cases where IOC indicated CBDS, no stones could be verified on exploration. In 4 of the 979 cases where IOC was normal, the clinical course indicated overlooked CBDS. CONCLUSION: Intraoperative cholangiography is a safe and accurate method for detecting common bile duct stones.

  • 39.
    Wells, Antonia C.
    et al.
    Cambridge Univ Hosp NHS Fdn Trust, Dept Surg, Cambridge, England..
    Kjellman, Magnus
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden..
    Harper, Simon J. F.
    Cambridge Univ Hosp NHS Fdn Trust, Dept Surg, Cambridge, England..
    Forsman, Mikael
    KTH, School of Engineering Sciences in Chemistry, Biotechnology and Health (CBH), Biomedical Engineering and Health Systems, Ergonomics. Karolinska Inst, Inst Environm Med, Stockholm, Sweden.
    Hallbeck, M. Susan
    Mayo Clin, Hlth Sci Res, 200 First St SW, Rochester, MN 55905 USA..
    Operating hurts: a study of EAES surgeons2019In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 33, no 3, p. 933-940Article in journal (Refereed)
    Abstract [en]

    BackgroundWork-related pain and discomfort experienced by surgeons is widely reported in the literature. A survey was, therefore, conducted to explore this issue among members of the European Association for Endoscopic Surgery (EAES).MethodsThe survey was emailed to 2980 EAES members in 2017 enquiring about their working practice, musculoskeletal (MSK) pain and burnout.ResultsA total of 569 (19%) surgeons responded, of whom 556 were practicing surgeons; 86% were consultants, 84% were male, and 94% were right-handed. Respondents operated on average 3.3days/week with 27% of their procedures lasting longer than 3h. The 386 endoscopists surveyed reported performing an average of 5.3 procedures/day with 83% performing endoscopy at least once per week. Over half of practicing surgeons (62%) reported their worst pain score was 3 or higher (10-point scale) in the past 7 working days, encompassing 71% of their open, 72% laparoscopic, 48% robot-assisted cases and 52% of their endoscopies. Of the 120 surgeons who had ever sought medical help for aches, pain or discomfort, 38% were currently in pain and 16% had considered leaving surgery due to their MSK pain, 26% had reported work-related pain to their employer, 26% had been on short-term disability during their career and 4% long-term disability due to MSK disorders. A significant proportion of the respondents (49%) felt their physical discomfort would influence the ability to perform or assist with surgical procedures in the future. These surgeons reported significantly lower satisfaction from their work (p=0.024), higher burnout (p=0.005) and significantly higher callousness toward people (p<0.001) than those not fearing loss of career longevity.ConclusionThe results show that MSK pain is prevalent amongst EAES members. Nearly half the respondents had career longevity fears from pain/discomfort which, in turn, correlated with more prevalent feelings of burnout. More emphasis should be placed on the aetiology, prevention and management of musculoskeletal pain in the surgical workforce.

  • 40. Wenner, Jörgen
    et al.
    Nilsson, Gunilla
    Lunds universitet, medicinska fakulteten.
    Öberg, Sven
    Melin, Tor
    Larsson, Sylvia
    Johnsson, Folke
    Short-term outcome after laparoscopic and open 360 degrees fundoplication. A prospective randomized trial.2001In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 15, no 10, p. 1124-8Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the lack of randomized trials supporting the laparoscopic approach, laparoscopic antireflux surgery has gained widespread acceptance during the last decade. The aim of this study was to compare the short-term symptomatic and objective outcome after laparoscopic and open 360 degrees fundoplication in a prospective randomized clinical trial. METHODS: Sixty patients with GERD were randomized to undergo either laparoscopic (LF) or open 360 degrees fundoplication (OF). Endoscopy, esophageal manometry, 24-h pH monitoring, clinical symptom evaluation, and symptom scoring according to a validated questionnaire (the Gastrointestinal Symptom Rating Scale [GSRS]) was performed preoperatively and 6 months after surgery. RESULTS: Five patients randomized to the laparoscopic group were converted to open surgery. Esophageal acid exposure was restored to normal in all patients. Lower esophageal sphincter length and resting pressure were significantly increased after both laparoscopic and open fundoplication (p < 0.001); there were no differences between the groups. No significant differences were seen in symptomatic outcome, although there was a trend toward a higher rate of mild dysphagia (p = 0.051) after laparoscopic surgery. GSRS revealed a decrease in reflux score (p < 0.001) and abdominal pain score (p < 0.001) postoperatively. There were no significant differences in GSRS scores between the two groups. CONCLUSION: Laparoscopic 360 degrees fundoplication is as effective in treating reflux disease as open fundoplication. Six months postoperatively, no significant differences were seen in symptomatic or objective outcome. Long-term evaluation is needed.

  • 41.
    GlobalSurg Collaborative, (Contributor)
    NIHR Unit on Global Surgery (Universities of Birmingham, Edinburgh and Warwick) University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
    Hjertberg, Maria (Contributor)
    Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping.
    Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study2018In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 8, p. 3450-3466Article in journal (Refereed)
    Abstract [en]

    Background Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. Methods This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. Results 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p amp;lt; 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p amp;lt; 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). Conclusion A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. Trial registration: NCT02179112.

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  • 42.
    GlobalSurg Collaborative, (Contributor)
    NIHR Unit on Global Surgery (Universities of Birmingham, Edinburgh and Warwick), University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
    Sund, Malin (Contributor)
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Andersson, Linda (Contributor)
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Gunnarsson, Ulf (Contributor)
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study2018In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 8, p. 3450-3466Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide.

    METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days.

    RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45).

    CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments.

    TRIAL REGISTRATION: NCT02179112.

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